RACGP prefers opt-in model for dispense notifications

Written by Kate McDonald on 12 March 2013.

The RACGP has clarified the reasons why it asked the two electronic prescription exchange vendors to disable automatic notifications that medications have been dispensed, arguing that the receipt of dispense notifications changes the current model of prescribing and has implications for doctors' duty of care.

Last week, the college met with the two electronic prescription exchange vendors, eRx and MediSecure, and requested they disable the automatic dispense notification functionality. MediSecure did so on Friday, while eRx will turn the functionality off tomorrow.

Several sources told Pulse+IT that one of reasons for the request was the increased concern over doctors being sued for not following up with patients, highlighted by the recent case of a morbidly obese man who sued his GP for failing to refer him to a weight-loss clinic or for surgery.

The sources said medical defence organisations in particular were concerned that cases such as this were changing the concept of duty of care and therefore doctors' liability.

RACGP spokesman on eHealth, Nathan Pinskier, said the recent case had added to concerns about duty of care, but it was in addition to the college's concerns over automatic notifications.

“[The case] certainly added to the concerns,” Dr Pinskier said. “It in itself is probably not the prime driver but it is a complicating factor in the currently confused environment.”

Dr Pinskier said the vastly increased use of electronic transfer of prescriptions (ETP) precipitated by the introduction of the new eHealth Practice Incentives Program (ePIP) had brought to attention a change in the current model for prescribing and dispensing that needed further investigation.

“We've got three models of prescription issuance and dispense that are operating at the moment in the country,” he said. “The first model is the current state which is essentially for most prescribing and that's the paper-based world. [As a GP] I write it, give the patient the prescription, they choose to take that prescription to the pharmacy of their choice, they choose to get it dispensed or otherwise and they choose to consume it or otherwise.

“In the current state, I have no awareness as to which pharmacy you have gone to and whether or not it has been dispensed and consumed until such time as you choose to return to me and we have a discussion and you inform me one way or the other.”

Dr Pinskier said the introduction of electronic prescriptions based on NEHTA's specifications, ETP 1.2, which is currently being considered by Standards Australia, would work on a similar model, only electronically.

“That works on a model of electronic prescriptions going up to a national system through a prescription exchange service but dispense notifications will not be directly returned to the prescriber,” he said. “There is no point-to-point dispense notification involved.”

He said two privacy impact assessments that were undertaken in 2009 to look at what would happen to the prescribing model after the introduction of electronic prescription exchanges found that as long as the information flow remained the same, it would not interfere with consumer choice, informed consent or any other potential privacy considerations.

However, the introduction of prescription exchange services has changed this model and information flow by sending information back to the prescriber, which raises the question of what the prescriber should then do about it.

“The advice that we have been provided around the model is that in terms of upload [to a prescription exchange], no consent is required as it maintains the current state – whether it is by fax or you take it to the pharmacy, it doesn't change the information flow.

“But the information coming back does change the current model in that I've got an obligation to notify the consumer.”

Asked if the pharmacist could capture the patient's consent at the time of dispensing by informing the consumer that their GP will receive a notification that the medicine has been dispensed, Dr Pinskier said it would be a solution to the consent process but not to duty of care questions.

“Does the general practitioner need that information, and what happens if they receive it and don't act on it?” he said. “If the script hasn't been dispensed, what is the GP's duty of care to follow that up and make sure they actually take it?

“Are we a surveillance authority, the medications police? There are no academic or legal or best practice models to support that, but we think it is best done as an opt-in system.”

Pulse+IT is still waiting for information from the Department of Health and Ageing about the exact date of the launch, and what it involves.

He said it was the RACGP's view that the NPDR, as an opt-in service for consumers registered for a PCEHR, would provide a new model.

“Subject to the patient's consent and their control, if they want to turn it on they will have dispense notifications going up to the PCEHR. The consumer can opt in and they can elect to share that information with their provider.

“That is a better mechanism because it informs, it is considered and it's controlled. I choose to share it and the provider chooses to look at it.”

He said the college had asked the two vendors to take a number of steps to resolve the issue in the meantime. The first is to redesign their software so that there is a controlled setting for the practitioner to turn on the dispense notification functionality.

They had also been asked to install the capability to later turn off that functionality, and to reconfigure the software to ensure that the practitioner is informed whether the setting was on or off for any particular patient. The vendors have also been asked to modify their terms and conditions.

Dr Pinskier said the college would look at developing some guidelines in collaboration with the medical indemnity insurers, the federal government and NEHTA to develop a best practice model.

Comments

The current e-Prescribing systems can only provide certainty that a medication has been dispensed, not that it hasn't. The later requires a 100% roll-out to all pharmacies, a common exchange, and possibly the end of paper scripts. Then, of course, there is the question of whether that medication is actually taken - as directed!

Therefore, I don't forsee a flood of patients suing their medical providers for a failure to ensure that they have collected and taken prescribed medications. The implication must be that the RACGP has a hidden agenda here, or that they've engaged inept lawyers who don't understand the law of negligence.

This annoys me - something that could potentially be useful gets caught up in masses of red tape and threats of law suits.

I would think it would be extremely simple. Just because the medication has been dispensed doesn't mean it has been taken. If a dr writes a prescription and the patient chooses not to have the prescription filled - why is it up to the dr to follow up.

Where's the personal responsibility?? A dr see's 2 -300 patients a week. On top of that they're then expected to go check each patients file to check if they have had their meds dispensed?

It protects more against people who go back and claim to have "lost" a script. By easily allowing the GP to check if they are lieing it reduces the risk of OD'ing or those drugs being on sold..

Perhaps I'm missing something, but the reasoning here appears a bit nonsequitur. The case of the obese man doesn't seem in any way related to the circumstances of the article.

If there was a case where a doctor was sued for not asking a patient if they saw the specialist they were referred to, that would seem pertinent. But the example given seems no more relevant that a doctor being sued for anything else.